经肛内镜显微外科手术-TEM医学医药

Treatmentof

rectaladenomas

by

transanalendoscopicmicrosurgery(TEM):

15years’experienceSurgEndosc.2009

姜海军第一页，共三十页。Backgroundpresentexperiencewithrectaladenomasmanagedbytransanalendoscopicmicrosurgery(TEM).Goal:evaluatingmorbidity,mortality,andlocalrecurrencerate.第二页，共三十页。PatientsandmethodsEnrolled:402patients,preoperativediagnosisofadenomas.(1993.1-2008.10)Meanage:65years(range22-92)Men:221vsWomen:181第三页，共三十页。distanceofadenomasfromtheanalverge0-3cm:28patients3-6cm:58patients6-12cm:251patients12-16cm:54patients>16cm:11patients第四页，共三十页。Lesionpositionanteriorwalloftherectum:92patientsposteriorwall:107patientslateralwall:88patientssemicircumferential:98patientscircumferential:17patients第五页，共三十页。Preoperativetherapystagingdigitalexaminationtoevaluatetumorfixationtotalcolonoscopyrigidrectoscopy:macrobiopsies;measurethedistancefromtheanalverge;determinethelocationandconsequentlyselecttheposition第六页，共三十页。transanalendosonography(EUS)byarotativeprobecomputedtomography(CT)scanormagneticresonanceimaging(MRI):giantandsuspectedlesions第七页，共三十页。Patientpreparationwashoutofthecolonshort-termantibioticprophylaxisgeneralanesthesiainthemajorityofpatientsSpinalanesthesiawasusedin65(16.1%)high-riskpatients(ASA4).第八页，共三十页。1.supineposition

2.proneposition

3.lateral

position

placethelesionintheinferiorpartof

theoperativefield第九页，共三十页。Fullthicknessexcision:379patients(94.3%)1cmminimumofnormalmucosaaroundthelesionMucosectomy:23patients(5.7%)第十页，共三十页。Meanoperativetimewas64min(range=22–120).rectaldefectwasclosed:endoluminalrunningsuturewithasilverclipplacedateachendofthesuturetoavoidanintrarectalnode.第十一页，共三十页。only15patients(3.7%)requiredtherepeatedadministrationofketorolac30mginthefirst48h.drinkliquidsonthefirstpostoperativedayMeanhospitalstaywas2.5days(range=1–8days).第十二页，共三十页。short-termresults:Minimalintraoperativecomplications:

13casesanopeningoftheperitonealcavityandin1patienttherewasanopeningofthevaginaAlllesionswereclosedendoscopicallybyTEMwithoutanyintra-orpostoperativeconsequences.第十三页，共三十页。giantadenomas(2cases):impossibletocarryoutacompletesuture.temporaryileostomyclosedafter2monthsOneofthetwopatientshadarectalstenosisrequiredendoscopicdilatation.Atfollow-upof24and30months(thepatientwithrectalstenosis)noothercomplicationswereobserved.第十四页，共三十页。DefinitivehistologyNFurthertreatmentadenomas366(91%).NOsitucarcinomaorpT1rectaltumor34(8.4%)NOmucinousT2cancer2(0.5%)laparoscopicanteriorrectalresectionwithtemporaryileostomy第十五页，共三十页。Postoperativefollow-up

meanfollow-up:84months(range=1–190months)1monthafterdischarge:①clinicalexamination,②digitalrectalexploration,and③rigidrectoscopyevery6monthsforthefirstyearandthenannually(flexibleendoscopywithbiopsiesofthescar)第十六页，共三十页。complications第十七页，共三十页。Allleakingsuturesresolvedbylocaltherapy(antibioticsandanalgesicenema)and/orparenteralnutrition.Stoolincontinencewastreatedwithphysiotherapyandanalsphincterbiofeedbackresolvedwithin2monthsoftheoperationThepatientswithhemorrhaging,twoofthemwithcirrhosis,requiredbloodtransfusions第十八页，共三十页。第十九页，共三十页。Surgicaldrainageandcolostomy(patientisaliveafter1year)LaparoscopicileostomyandanewsuturebyTEM.(patientisaliveafter2yearswithoutothercomplications)第二十页，共三十页。Long-termresults第二十一页，共三十页。Nopatientshadanewrecurrenceatthenextfollow-upOfthe34patientswithpT1rectalcancer,themeanfollow-upof30months(range=14–70months)revealednolocalrecurrencesordistantmetastases.第二十二页，共三十页。Discussionadenomasofthecolonandrectumhavethepotentialtobecomemalignant;relatedtosize,histologicaltype(villousadenoma),andgradeofdysplasia第二十三页，共三十页。Endoscopicpolypectomyisnotabletoremovealllargeandsessilepolypsduetotechnicalproblemsinthemiddleorupperrectum,itmaybedifficulttoexciseitcompletely第二十四页，共三十页。Sometimes,largeadenomasinthelowerthirdoftherectumaretreatedbyabdominoperinealexcisionorcoloanalanastomosisadenomasintheupperthirdoftherectumareremovedbyanteriorresectionResectionoftherectumisamajorsurgicalprocedureassociatedwithsignificantmorbidity(7–68%)andmortality(0–6.5%)第二十五页，共三十页。TEM:minimallyinvasiveandsafecanreachfurtherintotherectumthanotherformsoflocalexcision(upto20cmfromtheanalverge)第二十六页，共三十页。Risk:pelvicabscess,Infectionbleedingperforationintotheperitonealcavitysuturedehiscencestoolincontinence(soiling)rectovaginalfistula第二十七页，共三十页。indicationBenignlesion:polypsadenomasMalignantlesion:T1N0rectaltumor第二十八页，共三十页。Thankyou第二十九页，共三十页。内容梗概Treatmentof

rectaladenomas

by

transanalendoscopicmicrosurgery(TEM):

15years’experience。Patientsandmethods。Meanage:6